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11:U Langone
MEDICAL CENTER
Heis.pm Wyss Department of Plastic Surgery
305 East 33rd Street
New York, NY 1001
Patient Name: 5 e
— Fficel GPs-reiNI Date of Bette --cz Cl - 19 SS
Consent for Diagnostic & Treatment Photographs
I understand that photographs may be taken vi
connection with consultation. diagnostic testing. surgical procedu
physicians of NYU Plastic Surgery, Drs. Daniel Cern:M res and treatments by the
I. Roberto Fares, Mesas Hazen, Jamie Levine, Eduardo Rodrigu
Sharma. baud Stoltenberg, VEshal Thanlk, and Barry ez, Pierre Saadeh, Shoe
Zede or the Nine PractitionersAmanda Young, Kimberly Monon
NEcole Sweeney 1 understand that failure to consent to these a, Whitney Sala and
photographs wawa NYU Plastic Surgery the right to decline
my treatment
erAS -re u--I
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EFTA00313927
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73eb1b798d67aa05cb0e2c9fce5d5c0d8ae1b9db85c5c6a387fb5509d2f7a874
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EFTA00313927
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